Hongmei Li, Hongyan Li, Yifan Feng, Sarah Nalbandian, Zhonghua Fu
Introduction
In 1996, Dr. Zhonghua Fu, M.D., Ph.D. invented Fu’s subcutaneous needling (FSN). It is a type of acupuncture treatment in which singleuse specialized subcutaneous needles are used to perform procedures such as sweeping and reperfusion within the subcutaneous superficial fascia of affected muscles in areas of pain or in distal areas. For the last 27 years, FSN has been used widely for pain management, internal medicine, gynecology and the treatment of benign chronic pain. ［1］ FSN has great advantages such as wide indications, fast and precise efficacy, easy operation, and no side effects.
FSN Concepts: from FSN Medical Essentials
In October 2016, at the same time as the founding congress of the FSN Expert Committee of the World Federation of Chinese Medicine Societies, the first edition of FSN Medical Essentials was released in Nanjing by Peoples Publishing House. The first definition of FSN (TCM) is: FSN is the use of needles to perform widearea sweeping subcutaneously so as to unblock the sinews, quicken the network vessels, and stimulate the selfhealing ability of the human body, thereby achieving the goal of treatment without the use of medication. It is mainly used to treat neck, shoulder, lumbar, and leg pain as well as a number of internal medicine and gynecological conditions caused by sinew vessel blockage and blood stasis. The second definition (rehabilitation) is: FSN is a subcutaneous needling method that uses needle implements such as singleuse subcutaneous needles in the area around the affected muscle that is causing pain or on nearby limbs. Like traditional acupuncture, it is a drug free treatment method. When carrying out the treatment, it is often combined with reperfusion exercises. Compared to traditional acupuncture, treatment effects and feedback can be obtained more quickly.
In October 2021, A New Theory of Qi and Blood was released by People’s Publishing House. This is a book based on FSN medicine that integrates TCM and Western medicine. The definition of FSN in this text is: FSN uses single use subcutaneous needles to perform wide area, prolonged traction on subcutaneous tissues. By releasing the associated muscles, it promotes blood circulation, improves metabolism, and activates the human body’s selfhealing ability, thereby achieving the goal of treatment without the use of medication. It is mainly used for neck, shoulder, lumbar, and leg pain, as well as a number of internal medicine and gynecological conditions caused by tense muscles or other soft tissue, or blockage caused by blood stasis.
How does FSN differ from traditional acupuncture
The first difference is in the type of needle used. Initially, when using FSN, traditional acupuncture needles were used, i.e. filiform needles. At present, some practitioners use filiform needles to perform early tage FSN techniques, but this is not called FSN. The subcutaneous needle invented by Dr. Fu is an extension, development, and innovation based on the traditional needle. The most recent version of this needle is the fifth generation, FSN5.0.
The second difference is in the needle’s point of insertion. Traditional acupuncture points often combine the area of pathology and that of treatment, and the majority have fixed locations. For instance, the point Hegu ［LI-4］ is located at the midpoint of the radial border of the second metacarpal bone on the bulge of the muscle. By comparison, the needle insertion point in FSN is just the area of treatment and its location is not fixed. In FSN, the needle insertion point is chosen based on searching for the affected muscle in the area of pain, from which the area of treatment is determined. For instance, if there is lumbar and back pain with a bulging disc, the muscles to examine include the erector spinae, quadratus lumborum, external obliques, multifidi, biceps femoris, tensor fasciae latae, psoas major, rectus abdominis, soleus, and peroneus longus. Instead of searching for pain points, one looks for the affected muscle and procedures are performed outside of this muscle.
The third difference is in the area of needling： which is limited to the subcutaneous connective tissues. This is the key feature of FSN. FSN is a change from the norm; while conventional needling stimulates the epidermis, dermis, muscular fasciae, muscle, and even the periosteum with a perpendicular insertion, FSN is a transverse needling method in which only the subcutaneous layer of connective tissue and superficial fasciae is needled.
Needling techniques listed in chapter 7 of Ling Shu ［The Magic Pivot］, entitled “Official Needles”, such as hair needling, straight needling, surface needling, and half needling, are the theoretical origin and basis for the subcutaneous needle insertion technique of FSN.
FSN has a single target organ, the loose subcutaneous connective tissues. What it treats is the muscles, as affected muscles can cause many ailments in clinical practice. It reveals the reasoning behind the adage of treating a deeprooted illness with shallow interventions.
The fourth difference is in the needling techniques used. Techniques used with traditional filiform needles include lifting and thrusting, twirling, adjusting the direction, and supplementation and drainage. In contrast, FSN only uses the sweeping technique, including level sweeping and spiral sweeping.
The fifth difference is in the intensity and effects of stimulation: In traditional acupuncture, de qi ［obtaining qi］ is an important method and sign of clinical effectiveness, so in clinical practice, the majority of acupuncturists try to obtain qi as described in the text Biao You Fu ［Song to Elucidate Mysteries］: “The arrival of qi is like the floating and sinking of a fish swallowing a baited hook.” One of the standards for evaluating an acupuncturist’s skills is whether or not they can obtain qi. By comparison, FSN requires one to avoid making the patient feel qi sensations like soreness, distension, heaviness, and numbness. This is especially useful for acupuncturists practicing outside of China, as we often find that in clinical practice, patients complain, “I do not like de qi.”
The sixth difference is in the unique characteristics of FSN treatment: it is simple, safe, natural, non toxic, and yields quick results. Its efficacy is readily comparable to Western medicine, the procedures are 100% safe, and there are no side effects. It is also highly reproducible.
Six Unique Features
Find affected muscles instead of finding pain points and all procedures are performed outside the affected muscle. When sweeping, one must make the affected muscle move. Treating deeprooted illness with shallow interventions increases patient satisfaction. The needling is painless and harmless, and treatment outcomes are obvious and immediate.
FSN Procedures
Inserting the needle
Transporting the needle
Sweeping the needle
Retaining the needle
Removing the needle
The Thought Process Behind FSN Treatment
Definitive Diagnosis
Based on a full understanding of the etiology, pathology, condition, and duration of an illness, as well as the size of the affected area and its location, one can take into account the location, severity, and quality of pain to perform a comprehensive analysis and thereby clarify the diagnosis to determine whether or not the case is within the scope of FSN treatment. This is the first question to consider in clinical practice because it is only possible to obtain the best clinical results if the diagnosis is correct and fits the scope of FSN treatment.
Here it is necessary to emphasize that no treatment method is universally effective. FSN is not effective for treating all illnesses and pain. In clinical practice, we must sincerely evaluate and screen for indications. If we have yet not seen the patient and the relevant examinations have not been done, we must not make any promises.
1. Definitive Needle Insertion Point
The correct direction for needle insertion is the prerequisite for treatment effectiveness. The tip of the needle must be inserted from the distal to the proximal end in vertical alignment with the affected muscle. The selection of the needle insertion point is based on finding affected muscles in the area of pain and confirming the area of treatment. The principles are:
1) If the area is small and there are few affected muscles, a proximal needle entry point is best, while a distal point should be used for a large area with many affected muscles.
2) Needling should be done starting from distal locations and moving to proximal locations, e.g. most chronic lumbar pain complaints are accompanied by abnormal findings of the lower limbs, so the selection of needle entry points should start in a distal area and then move to proximal areas.
3) In most situations, it is sufficient to choose a needle insertion point above, below, or to the left or right of the affected muscle.
4) Try to avoid superficial blood vessels, so as not to cause bleeding and pain.
2. Sweeping
The sweeping procedure is a distinctive feature of of FSN. It refers to waving the body of the needle left, right, up, and down in a series of movements after the needle has been transported and before removing the needle. The sweeping motions should be large, steady, and rhythmic, not seesawing or varying in speed. One must maintain focus when performing the sweeping procedure. The practitioner must be closely aware of the sensation under the needle and the patient’s reaction.
There are two kinds of sweeping: level sweeping and spiral sweeping.
Time for sweeping a needle entry point: usually about 100 sweeps/minute for 2 minutes
Many features of FSN are clearly present in Huang Di Nei Jing; this is to say that many of the characteristics of FSN are scattered throughout the various needling techniques in Huang Di Nei Jing. In terms of true innovation, the FSN sweeping method is completely new, as well as the special needling implements used.
“Pierce the skin without touching the muscle, then sweep left and right. Natural reperfusion boosts patient satisfaction and achieves quick results.”
3. Needle Retention for 24 Hours is Preferred
When removing the needle, it is best to use a bandage and press for 1 minute to prevent bleeding.
4. Reperfusion: Resistance exercises, to be discussed in detail at a later time.
We have been implementing FSN in many cases at the hospital of CedarsSinai Medical Center (CSMC). In some cases, only FSN is used, although most patients are treated by FSN combined with traditional acupuncture. FSN has been able to help support certain pathways in the body that are associated with pain and inflammation. Several FSN case reports are provided below:
Case1: Temporomandibular Joint (TMJ) in a Pregnant Patient
The patient was a 30-ear-old American female. The initial intake was on July 3rd, 2020.
Chief complaint: Stiff, sore, and painful lower jaw muscles for 2 weeks.
History of present illness (HPI): The patient stated she was 16 weeks pregnant with her second child. Two weeks before, she started to feel stiffness, soreness, and pain in the muscle of the lower jaw, with a pain level of 9/10 as well as clicking and popping, and popping sounds in her ears. The pain made it impossible for her to sleep at night.
Past medical history: She previously came to the clinic in 2017 for lumbar pain, which was treated successfully.
Physical exam: Affected muscles were suspected to be the masseter, temporalis, and sternocleidomastoid. Palpation: Muscles were tense, stiff, hard, and slippery.
Differential diagnosis: Facial spasm, trigeminal neuralgia
Initial diagnosis: Acute mandibular arthritis
Treatment process: With the patient supine, the masseter and sternocleidomastoid were chosen for FSN treatment. The needle tip was aimed at the affected muscles and inserted, then slowly transported. Level sweeping and spiral sweeping procedures were used. The treatment was divided into two parts, each of which involved sweeping 100 times/minute, for a total of about 200 sweeps in 2 minutes. The whole treatment process lasted 60 minutes.
Immediate effects: After one session of FSN , the patient reported that her pain had decreased by 90% and she felt much more relaxed. She cheered: “It’s a miracle!”
Medical advice: The patient was advised to come back soon for a followup. She was advised to avoid using cold water to wash her face, and use warm or hot water instead. She was also advised to enhance her diet by eating foods high in protein and vitamins.
Follow up: After a week, the patient called to report that the pain was under control and the sounds were gone. At the time of follow up 1 year later, the patient’s TMJ complaints had not recurred.
Case Analysis and Discussion:
1. Temporomandibular joint disorders can cause pain in the mandibular joint and the muscles that control the mandible. The target tissue of FSN treatment is the muscles, so FSN is indicated in this case. Therefore, the diagnosis has been clarified. (TMJ disorders will often cause difficulty chewing and talking, so although these illnesses are not fatal, they will influence a person’s quality of life. If they are not brought under control, symptoms will often worsen and cause chronic issues.)
2. In comparison to traditional acupuncture treatment for TMJ disorders, FSN’s immediate effects are unparalleled. One FSN treatment can fully resolve the pain.
3. At present, FSN’s analgesic mechanism is unclear. Sweeping stimulates the sternocleidomastoid, so it may indirectly block the transmission of neurotransmitters or directly block the nerve roots from transmitting pain signals to the brain, thereby obstructing the feeling of pain. Could it have the same effect as a nerve blocking anesthetic? This would cause the patient to feel the pain has decreased or disappeared.
4. Using FSN to treat TMJ will definitely yield results. It may enable the patient to avoid invasive treatments like surgery. In the majority of cases, the pain and discomfort associated with temporomandibular joint disorders is temporary, and can be mitigated with selfcare and nonsurgical measures. Although surgery is often a last resort after conservative measures have failed, a few patients with temporomandibular joint disorders may benefit from it.
Figure 1: Pregnant woman with TMJ symptoms treated by FSN
Case 2 Cervical Pain
The patient was a 30-year-old American female. The initial intake was on June 15th, 2021.
Chief complaint: Rightsided neck pain for 1.5 years.
HPI: The patient was a 30-year-old female who was referred to FSN by her Western medical provider for right sided neck pain. The pain level was 6/10. In October 2019, after the patient was involved in a car accident, she felt sharp pain in her neck that radiated to the right shoulder. She had difficulty turning her head left and right, and felt pain while doing so. She did not go to the emergency room at that time. Later, she sought Western medical treatment, took pain medication, and had two cortisone shots, while also undergoing physical therapy. Unfortunately, while her pain had improved after nearly 2 years of treatment, there was no noticeable effect.
Past medical history: No other history of injury.
Physical exam: Right neck and shoulder tension with pressurepain. Limited range of motion.
Muscle exam: Trapezius, levator scapulae, splenius capitis, splenius cervicis, sternocleidomastoid, scalenes, supraspinatus, infraspinatus; at times even the deltoid, brachialis, and brachioradialis are involved.
MRI diagnosis: Cervical spondylosis
Treatment process: The patient was seated with the head facing left. The muscles chosen for FSN treatment were the sternocleidomastoid, trapezius, levator scapulae, supraspinatus, and infraspinatus. The needle point was aimed at the affected muscles, slowly inserted, and swept. The treatment was divided into 2 parts, each of which consisted of 100 sweeps/minute, for a total of 2 minutes. The whole treatment process lasted 60 minutes.
Immediate effects: After treatment, the patient reported that the pain had decreased by 70%. She said that out of all her treatments, FSN was the most effective treatment method, so every time she came, she would mention wanting to “fire the gun”, i.e. she wanted to get FSN treatment.
Treatment outcomes: After 5 FSN treatments, the patient’s pain level decreased to 1/10.
Medical advice: 1) Avoid carrying or lifting heavy objects. 2) Keep the neck area warm and avoid exposure to cold. 3) Exercise as appropriate.
Case Analysis and Discussion:
The method used here was: bombarding distal areas, starting from distal areas and moving to proximal ones. The FSN treatment started with the deltoid, supraspinatus, and sternocleidomastoid, and finally reached the levator scapulae. The cervical nerve and carotid vein and artery run through the neck area. Because FSN sweeps the subcutaneous loose connective tissues, it may increase the blood flow to the neck muscles, thereby also increasing the blood supply to the face. It may also be that the mechanical stimulus functions to block the cervical nerve roots from sending pain signals to the brain, thus decreasing the patient’s pain.
Case 3: Bulging Lumbar Discs with Lower Back Pain and Urinary Incontinence
The patient was a 32-year-old American male hospital inpatient.
Chief complaint: Lower back pain for 2.5 years
The patient was a 32-year-old male. He was admitted as a hospital inpatient for lower back pain, bulging lumbar discs, and unintentional weight loss. The patient presented with worsening lower back pain and acute urinary incontinence. Upon admittance to the hospital, he was given oral analgesic medication, 1 epidural injection, and a ketamine IV drip, which reduced his pain.
At the time of intake, the patient was seen lying down on the bed, with his wife at the bedside. The patient reported lumbar pain that radiated towards his legs, with a pain level of 8/10, and frequent urination, about 14 times/day. He also reported positional headaches.
Physical exam: Pressurepain, limited range of motion.
MRI (Magnetic Resonance Imaging): Mild cervical spondylitis, bilateral L5-S1 has severe foraminal narrowing.
MRI cervical, thoracic, and lumber myelogram: Small upper thoracic perineural sleeve cysts.
Treatment Process: Because the patient’s condition was relatively complicated, he was treated using Jiao’s scalp acupuncture and FSN.
1. For Jiao’s scalp acupuncture, the foot motor sensory area and psychoaffective area were selected.
2. FSN: Suspected muscles examined: erector spinae, quadratus lumborum, external obliques, multifidi, biceps femoris, tensor fasciae latae, psoas major, rectus abdominis, soleus, and peroneus longus.
Diagnosis: Bulging lumbar discs
The point of the needle was aimed at the affected muscles, namely the erector spinae, quadratus lumborum, external obliques, rectus abdominis, soleus, and peroneus longus. The needle was slowly inserted and then swept. The treatment was divided into 2 parts, each of which consisted of 100 sweeps/minute, for a total of 2 minutes. The whole treatment process lasted 60 minutes.
Immediate results: After the first FSN treatment, the patient reported that the pain had noticeably decreased by 70% and the headache was under control. He could get up from the bed and stand up, and he was able to take a shower unassisted the same day.
Treatment #2: The patient’s main complaint was lumbar pain, 2-3/10, which had improved greatly. However, he experienced urinary incontinence about 14 times a day. He requested FSN treatment.
Treatment outcomes: After receiving 2 FSN treatments, the patient’s pain level decreased to 3/10. Urinary frequency decreased to about 7 times a day.
Treatment #3: The patient’s main complaint was lumbar pain, 2/10, with a noticeable improvement in the pain. The urinary incontinence was already controlled and returned to normal.
Treatment outcomes: After receiving 3 FSN treatments, the pain level had decreased to 3/10. Urinary frequency had returned to normal.
Medical advice: 1) Avoid carrying or lifting heavy objects. 2) Keep the back warm and avoid exposure to cold. 3) Exercise as appropriate. 4) Eat a diet high in protein and vitamins to gain weight. 5) After discharge, continue acupuncture treatments 2 times a week. Follow up in 2-3 weeks.
Case Analysis and Discussion:
1. This case was relatively complicated, so the patient was treated using Jiao’s scalp acupuncture and Fu’s FSN simultaneously. As he was a hospital inpatient, we provided acupuncture treatments in our capacity as TCM practitioners, while Western medical practitioners provided medication. This integration of TCM and Western medicine allowed the patient to receive the best physical and mental care possible.
2. FSN treatment mainly focused on the lumbar and back pain, as well as the urinary incontinence.
1) Low back pain: The majority of scholars believe that possible mechanisms by which bulging discs cause lumbar and leg pain include: A. mechanical pressure, i.e. the bulging vertebral pulp places acute pressure on the nerve roots, causing symptoms of lumbar and leg pain, with the size of the bulge directly affecting the level of pain; B. inflammatory response, i.e. the bulging vertebral pulp is a biochemical and immunological irritant that causes an inflammatory response in the surrounding tissues and nerve roots.
We used FSN to treat bulging vertebral discs that caused lumbar and leg pain with swift results. In this case, 3 treatments achieved clear effects. The mechanism behind this may be that the widearea sweeping of subcutaneous connective tissue in FSN improved the blood supply to the affected muscles and reduced muscle shrinkage, causing the bulging vertebral discs to retract and thereby relieving the pain by eliminating the pressure on the nerve roots.
Most lumbar pain is caused by the lower erector spinae or quadratus lumborum. Typically, the “remote bombardment” method is used, proceeding from the distal to the proximal, mostly on the peroneus longus or the lower portion of the gastrocnemius. The needle is inserted from bottom to top, and reperfusion exercises are done against resistance.
2) Urinary incontinence: This is usually due to the pelvic floor muscles and vesicourethral sphincter not functioning normally. It manifests most visibly when there is increased abdominal pressure, e.g. when coughing, sneezing, laughing, or doing physical activity, which causes urine to be discharged from the urethra. In severe cases, this may happen when walking or standing up. In this case, the bulging lumbar discs and affected muscles increased the abdominal pressure, causing urine to flow out.
The main suspected muscles include: the lower rectus abdominis, thigh adductor group, medial head of the quadriceps, and the soleus.
In this case, FSN treatment was performed on the soleus and lower rectus abdominis, yielding excellent results.
3. FSN treatment played a crucial role in this case. It yielded good realtime results with a high level of efficiency and safety, and had no side effects.
4. FSN increased the hospital bed turnover rate and decreased the duration of inpatient stays.
Figure 2: Inpatient with lower back pain and urinary incontinence
About the Author:
Hongmei Li Senior acupuncturist Cedars-Sinai Medical Center ，Los Angeles, CA.
Hongyan Li Senior acupuncturist Cedars-Sinai Medical Center，Los Angeles,CA.
Yifan Fang Acupuncturist Alternative Medical Center,Los Angeles,CA.
Sarah Nalbandian, Student at University of California, Los Angeles, CA.
Zhonghua Fu Clinical Medical College of Acupuncture & Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine
The Institute of Fu’s Subcutaneous Needling, Beijing University of Chinese Medicine.
References
1. Zhonghu Fu, the foundation of Fu’s Subcutaneous needling, People’s Medical Publishing House(PMPH), ISBN 978-7-117-23380-4/R·23381
2. Zhonghua Fu, Ryan Shepherd . Fu’s Subcutaneous Needling, a modern style of ancient acupuncture. J. Acupuncture in modern medicine. 2013; 06(3) DOI: 10.5772/53970
3. Zhonghua Fu, YuehLing Hsieh, ChangZern Hong, MuJung Kao, JaungGeng Lin, LiWei Chou, Evid Based Complement Alternat Med. 2012; 2012: 353916. Published online 2012 Dec 25. doi: 10.1155/2012/353916PMCID: PMC3544156
4. Ching Hsuan Huang, Lung Hung Tsai, Mao Feng Sun, Zhonghua Fu, Jian Sun, Li Wei Chou, Rapid Improvement in Neck Disability, Mobility, and Sleep Quality with Chronic Neck Pain Treated by Fu’s Subcutaneous Needling: A Randomized Control Study, Pain Res Manag. 2022; 2022: 7592873. Published online 2022 Sep 30. doi: 10.1155/2022/7592873 PMCID: PMC9553660
5. Yaping Li, Xianghui Gao, Hailiang Huang, Xiyan Zhou, Yunhua Zang, LiWei Chou, Effects of Fu’s subcutaneous needling on mitochondrial structure and function in rats with sciaticaMol Pain. 2022; 18: 17448069221108717. Published online 2022 Jun16. doi: 10.1177/17448069221108717 PMCID: PMC9210095
6. Jiangxia Yang, Chen Yang, Yajie Wang, Ning Li, Xingzhang Yao, Bowen Yang, Xia Xu, Xingyong Li,Effect of subcutaneous needling on visual analogue scale, IgG and IgM in patients with lumbar disc herniation. Medicine (Baltimore) 2020 Feb; 99(9): e19280. Published online 2020 Feb 28. doi: 10.1097/MD.0000000000019280 PMCID: PMC7478818
